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Southern Health report shows we don’t learn from past mistakes

In this guest blog, Simon Cramp says the latest Care Quality Commission report on Southern Health shows how lessons from past mistakes have not been learnt – and that this has to stop.

Another week, another report on failings at Southern Health NHS Foundation Trust and the debacle of Justice for LB.

The background to this case is well known. Connor Sparrowhawk – ‘Laughing Boy’ or ‘LB’ for short – drowned in a bath while at an assessment and treatment unit run by Southern Health in 2013. There followed an inquest, serious case review and then an independent report in December 2015 by Mazars, which was commissioned by NHS England. The Mazars report pulled no punches on the failings at the trust.

Now, we have had a report by the Care Quality Commission (CQC) of its latest inspection of Southern Health, conducted over 4 days in January.

The critical report highlighted serious concerns about the safety of patients with mental health problems and learning disabilities in some locations operated by Southern Health. The CQC’s inspection found that many of the previously reported failings – especially in relation to governance, patient safety and ability to respond to patient concerns – were still evident.

In addition, the board of Southern Health were criticised for showing little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies.

The report is very powerful and the question is how does it move on the issues of stopping things like reducing sudden deaths and making sure when they do happen the process is more transparent and that due process is done correctly – i.e. deaths are properly investigated?

It was interesting that on the eve of the report being published the chair of the board of Southern Health, Mike Petter, resigned.

I would be very unhappy as a worker and as a service user to get this sort of service.

At Southern Health the troops on the ground are working really hard – as the CQC report noted – while the leadership is seemingly non-existent. I would call on Southern Health’s CEO, Katrina Percy, to ask herself the question that Andrea Sutcliffe, chief inspector of adult care at the CQC, always poses: would I be happy for my mum or dad to use these services?

I bet this service doesn’t meet the mum test. There is a big rebuilding job to do at the trust and Health Secretary Jeremy Hunt and the board of Southern Health have questions to answer. They keep referring to something that was being promised and implemented last December and yet there are still problems.

As a service user, I would not put up with this and we don’t seem to learn from past mistakes and scandals because they keep on happening. It has got to stop.

About the author

Simon Cramp is a fellow of the Centre for Welfare Reform and a service user